Thursday, December 27, 2012


  As I said in last blog , I often see patients who are sick , or remarried or have complex family issues . The story that I am going to tell is not unusual, but was unexpected in this family , at least I thought so .
   I saw this 78 years old patient for allergies and asthma . He was fairly stable , except when he would get bad sinus infection . Then he would get lot of coughing and fever and even shortness of breath as he also had mild asthma . He was OK but then his healthy looking wife was diagnosed to have brain tumour and then continued to get worse . She died in very short time . It was a shock to him and me too. He had a friend and she helped him during his wife's illness .Within short time after his wife died ,he married her .She was same age as him and was married twice before . Her both previous husbands had died . She had no children of own . They were married and then both of them continued to come to me .As he got older , his health continued to deteriorate . He was diagnosed to have Parkinsonson's disease and then congestive heart failure . He was getting more short of breath. He was 84 years old and was not a candidate for any surgery . The new wife had sleep apnea and mild asthma .She was doing quite well . . But he was not well. I had admitted him few times and even when he came for follow up , he was unable to walk much without getting short of breath .
I had talked to them about respirator and CPR and other things , like 'life support '. He had told me that he did not want to be prolonged , but wanted to "give it a try .". This is always very difficult as doctors don't have 'crystle ball to know ' as to what is going to happen in future.
     Then it happened .He was admitted to the hospital with shortness of breath . He was in ICU. I saw him and talked to him and his wife . We decided that we wanted to do everything for now . In next hour or so he was put on respirator .He had pneumonia and congestive heart failure . The new echo cardiogram showed that his heart was quite weak . In next few days he continued to go down , with problem with blood pressure and urine out put and then with oxygenation . I was talking to the wife , who was medical power of attorney . I was not aware of any children . I had not seen any one even when his 1st wife died ,so I was surprised when I got a call from "his son". I talked to his current wife to whom he was married for  atleast 6 years . We were talking of withdrawal of life support as he was not doing well and he did not want to be just left alive if there was no hope . She agreed and then I got the phone call .The son wanted to come before he died . When I talked to the wife , she told me that this son had never called or kept in touch except when he wanted money . Over period of time he had given him thousand of dollars with the promise that he would return and he had never returned any . We postponed the withdrawal for one day and when the son arrived we ended up doing the withdrawal of life support . He died in less than 15 minutes .
      The son was quite mad that the father had left nothing to him in his will . He tried to challenge it and nothing got changed . He called me and wanted to know if his father was in 'sound mind ' I do agree that I have only one side of the story , though I feel that it is quite accurate . I am not sure where was the love . I do believe that the marriage was due to necessity and I do believe that the 'love ' did develop latter on , but I don't think that that the son had any love , other than for his money .

Wednesday, December 26, 2012


   I often see patients who have sometimes real complaints , at times fake complaints and at times about other family members . Sometimes it is funny , sometimes it is sad , but one thing for sure that I often hear only one side of the story . The stories that I am going to tell are such stories .
    I had seen him for many years . He was close to 90 years of age . His wife was 90 years old .He was diagnosed to have lung cancer about 6or 7 years ago . Taking in to account his age and lung capacity , he was not a good candidate for surgery and so was treated with radiation therapy . He did well and was considered 'cured ' of the cancer as there was no evidence of the cancer in follow up scans and since 7 years had passed , he was cured .One day he came with his wife as he did usually. As I entered the examination room , and asked him as to how he was doing , he answered, "my wife does not love me any more ". I asked him 'why do you think that way?' He told me as to what had happened last night .Night before his appointment , he could not fall asleep and at 1or 2 am he started having some vague chest discomfort . So he woke his wife and told her about it . She said ,"go to sleep for now ." . When he could not fall asleep , he woke her again . He told her that he still had the discomfort and he may die . She told him to turn on other side and die . and she will take care of his body in the morning . He did not like it and was complaining that she does not love him anymore ..When I asked her , she told me that when he can't fall asleep , he gos on complaining about things . Again after 60 plus years of marriage , she did love him .But he was telling me that she does not love him any more .

Sunday, December 23, 2012


   I did mention some incidences of physicians who neglected their own health , not sure if it was due to'fear' or shear neglect or feeling of invincibility.In any case their diagnosis gets delayed and outcomes are not all ways favourable . The next story is that of someone I knew.
   This physician was a lung specialist . He was quite overweight or even obese . (now a days if body -mass-index is 25 to 30 , it is called overweight , if it is more than 30 , it is called obese .)He had some shortness of breath and some neck pain . Our job involves misuse of neck . We hold phone by our shoulder and twisting neck , we do many procedures with neck being bent all the time and even writing or working on computer does same thing. This leads to arthritis  of neck . He did CT scan of cervical spine and found out that he had pinched nerves . He had attributed his shortness of breath to being overweight .He had the spine surgery . His pain was better , but the weakness in arms continued to get worse . So now the further work up was done and it showed that he had ALS. In this disorder there is degeneration of spinal column and this leads to weakness and then paralysis , which continues to get worse and one can become quadriplegic . In advanced case they will need respirator and a feeding tube . Once the diagnosis is established , the prognosis was clear and so was the treatment . We as physicians advice tracheostomy to help handle secretions and feeding tube to avoid aspiration and the respirator . HE SAID NO TO EVERYTHING , KNOWING FULLY WELL THAT HE WILL DIE WITHOUT THIS HELP . In this case the diagnosis was not that delayed and even if it was done few months earlier , it would not have changed the outcome , and this brave physician decided not to go through 'torture ' of treatment .(Stephen Hawkins has same thin and he has full support ).

Saturday, December 22, 2012


22.When we surrender oneself to you , then we get all the pleasures .When you protect us , why should I have any fear.
23.When you roar, people in all 3 worlds start shaking in fear.
24.When we chant your name , ghosts will not dare to come close.
25.When we chant your name all diseases and all problems will go away.
26.When one devotes to Hanuman, with mind,action, speech,and concentration,(DHYAN),he will get rid of any difficulty.
27.You consider King Rama who is also Yogi, as supreme and you are all ways ready to do any work for him .
28.Anyone who tells you his desire,he gets what he desires and gets long life.
29.Your fame or bravery is known in all 4 Yugas.(Kruta, Treta ,Dwapar and Kali)and because of of you the entire world is enlightened .
30. You (who is loved by Lord Rama ) protect Yogis and devotees. You destroy the rakshashas.
31.Mother Janaki gave you a boon that you can give 8 sidhis(miraculous powers ) and 9 different types of monitory things .
32.You have magical chemical called Rama and so you live for ever.(there are in Indian scripture there are few people who are thought to live for ever , Hanuman is one of them ).
33.Worship or chanting for you goes to Lord Rama and it eliminates sorrow from many lives.
34.At the end of life, with devotion to you ,one goes to Ayodhya(place where Lord Rama was born ), and being born there is considered to be devotee of Hari (Lord Krishna ).(Rama is reincarnation of Lord Vishnu , so is Lord Krishna )
35.One does not need to worship any other Devata ---god as devotion to Hanuman will give all happiness.
36.When one thinks of Haanuman , all difficulties go away .
37.Controller of the all senses , Lord Hanuman , Victory to you, bless me like any teacher would do .
38.When one repeats these 40 shlokas 100 times.he will be free from all bandages and will achieve great happiness.
39. When one reads this Hanumanchalisa , his desires will be fulfilled .Lord Shankar is witness to this fact .
40.Tulasidas is devotee of Hari and Lord (please) reside in my heart (for ever ), This is my request.

O removal of all difficulties , ,son of Wind Hanuman , tour look is very auspicious .O protector of gods and the earth , please reside in my heart along with Lord Rama, Lakshuman , and (mother )Sita .


    I have been  a physician  for longer time than I have been not a physician . I have noticed several things about physicians . These are only my observations and may not be validated by others. We physicians are the only people who can neglect our family , who can neglect their health , and will be considered 'great ' physician . "HE IS SO GOOD THAT HE DOES NOT CARE IF HE HIMSELF IS SICK OR IT IS A HOLIDAY ETC " are the statements that we here and 'feel ' good . Son it is not a surprise that many a times diagnosis of illness is delayed  and we pay dearly for it . It may also have to do the facts that since we know the medicine , we are 'afraid ' of the diagnosis and , so avoid doing the tests that could make the diagnosis earlier . Let me give some examples .
    I was standing in a doctor's lounge , trying to eat before I had to go to the office . I had may be 5 minutes at most .In past and even today I sometimes eat in the car , while going to office and have stains of ketchup to prove it . But this time I was eating in the room and was with couple of female doctors . I saw a male surgeon walk in the lounge . I had called him for a consult few weeks ago and was told by the covering physician that he had open heart surgery --a coronary bypass . So I was happy to see him back . I told the other 2 female MD . and asked them if they knew that he had a bypass surgery .They had heard that he was 'out ' but did not know exactly as to why . They asked me if had problem with the heart before . I told them I did not know . How come he did not know that he had heart problem , they asked . I said , "two reasons , one he is a doctor and second is that he a male doctor . "When the surgeon came towards me I asked him about his health. As predicted , he never had any testing done . nor had he gone to physician for routine check up . (He is 67 yrs old .)
     The second story is that of a another friend of mine . He was a gastroenterologist . One day he called me asking me if I knew any good surgeon . I was surprised as he was himself a physician. He told me that he had hernia and needed a surgeon that operated in the hospital, that not too many people knew him .I told him couple of names and asked him as to what was the problem . He told me that he had vague belly pain and he thought that it was due to the hernia that he had . He did get an appointment with a surgeon , but did routine blood tests before going to him . To his surprise , his liver tests (blood enzymes )were not normal . So he did ultrasound of liver and then CT scan . HIS LIVER WAS FULL OF CANCER . Further investigation showed that he had cancer of the stomach . He died in less than 6 months after the diagnosis. His belly pain and weight loss was due to cancer and not due to hernia . (and I am sure he might have suspected it , but never thought of working it up like any good doctor would do ---like himself  and paid price for it )
    Just add a personal story , I had a hernia and I knew about it for at least 3 years before I decided to get operated . .(The size was such that at times I had to reduce it in public , making sure no one was watching.)I was scheduled for the surgery on Wednesday before Thanks Giving .I completed my "hospital rounds ". Then at one pm checked myself in , had surgery at 3 pm and went home at 6 pm . I was back to work on Monday . ( If I was allowed to start the work on Saturday by my wife I would have done that too )
    The next story is that of a young cardiologist. He had a dizzy spell and then passed out . The family called 911 and he was taken to a ER . CT scan of brain was done and it showed that he had bleeding in the brain . He had no medical history . He was transferred to other hospital , but he was gone . He was brain dead and family decided to stop everything . He was not even 50. I was talking to a ward secretary ,few days after this incidence . She told me a story which shocked me . One day this cardiologist was making round and this ward secretary asked him she could help him . (by getting charts or labs or calling RN etc . ) He said that if she wanted to help him she could get some ibuprofen as he had headache  . She gave him 400mg of Advil (which is usual dose ). He said , he needed 800mg to 1200mgs to relieve 'his' headache. She did give the dose . In retrospect if a patient came to me with a complaint of headache that needed such a large dose , I would have sent him for STAT CT scan of brain . My suspicion is that he had an aneurysm , that ruptured and he died of the bleed . COULD WE HAVE SAVED HIM IF THE CT SCAN WAS DONE EARLIER ?DID HE NEGLECT HIS OWN HEALTH ?----YOU DECIDE .

Tuesday, December 18, 2012


   12.Lord Rama was pleased and he hugged him and praised him and told him that he (Hanuman ) is like my brother Bharata.
    13,14,15..The king of cobras , the SHESH, will sing your praises with his 1000(thousands of )mouths.(In Hind concept the Shesh Nag or Cobra is the bed of Lord Vishnu , and the lord Rama is reincarnation of Vishnu . when it is said thousand , it means many thousands. )But also Sanak (muni or rishi ) Brahmadev(creator of the universe)many Rhishis, Narad(the Indian scripture Reporter who can travel to earth or heaven )Sharada, ( who is Goddess of knowledge ),King of snakes , Yama (Lord of death )Kuber (treasurer of the heaven ), etc,poet Govind are unable to describe your greatness.
    16.You were instrumental in meeting of Sugriv and lord Rama, in turn (due to Rama's blessing ) Sugriv became the king.
     17 .Taking your advice , Bibhishan(becoming friend of lord Rama) became king of Lanka .
      18 The Sun which is .thousands of mile away ,looked like a sweet fruit to you and you jumped to get it .(this occurred when Hanuman was borned . When he started to go towards the Sun , lord Indra , the king of Gods, got concerned and threw his Vajra )
      19.You jumped the entire ocean. with the ring held in mouth given by lord Rama, to go to Lanka . ,but that is not a surprise.(as the distance between the earth and the Sun is far more than between Lanka and the India and you were blessed by the Lord Rama .)
      20.The difficult task becomes easier and winnable , with your blessings .
      21.You are the security guard for the lord Rama (so without your permission we can't get to Lord Rama .)You do not leave Him without His order .

Monday, December 17, 2012


   1.Jay to Lord  Hanuman ,who is knowledgeable and is like ocean of all the good qualities.Jay to that greatest of the monkeyes . He is enlightening all 3 lokas (the earth, the heaven and ,PATAL, which is bellow the earth .)
   2.He is the messenger of the Lord Rama and is home of the strength(that means all the strength starts from Him ).He is the son of Anjani and is known as or famous as son of Lord wind (PAWANSUT ).
   3. He is great warrior and his body is strong as Wajra.(famous weapon )Let him control our bad thoughts(and intellect) and promote good intellect.
   4.He has golden color.(which is shining ),so he looks great,with earring in the ears and has curly hair.( Hanuman was told how to 'identify lord Rama . He was told that one who identifies his golden undershorts , is the lord Rama . )
   5.He is holding aWajra like Gada and he is holding a flag in other hand .On his shoulder is the sacred thread called Janoyi. (in ancient time when the child became of age to start study or become student, there is a ceremony performed , in which he starts wearing this Janoyi ).
   6.He is reincarnation of the Lord Shiva(with his blessing , he is no other than Rudra ) and he is son of Monkey named Kesari . He is such great warrior that entire world bowes in front of him .
   7.He is very intelligent ,he is very smart, and is very eager to anything for the lord Rama.
   8.He is very keen on listening to the life story of lord Rama as Rama. Sita and Lakshuman are seated in his mind .
   9.He took very small size when was meeting Sita , and became big to set fire to the Lanka .
   10.He was huge , when he destroyed many Rakshashas and was very helpful in the work of  lord Rama.(in destroying Rakshsashas ).
  11. He brought medicine called sanjiwani and so Lakshman survived . This made Lord Rama very happy and he hugged Hanuman .(when during the war with Rawan ,Lakshman became unconscious. So to save his life they needed medicine to be brought from a far away mountain called Mandradri. Hanuman lifted entire mountain and brought it as try to find the medicine would have wasted the time . )

Sunday, December 16, 2012


     The Hanumanchalisa is 40 shlokas , which were written by Tulasidas.It is a song related praise of Lord Hanuman . It has 40 shlokas , which is why it is called 'chalisa '.The Lord Hanuman is the so called 'monkey face Indian god. His mother was Anjani, and father was  Kesari . He is also the son of  "wind God ". So in an indirect way he is 'half brother ' of second of the Padawas , BHIM .In Indian mythology there is symbolism . One  reason we have Gods with different faces, is that we believe that there is a reflection of The GOD in every one of us. This has to do the fact that there is nothing that was not made by the God . So there is nothing outside Him . So if he made us,  we must have element of Him . This hold true for everything in this world . The second reason is symbolism . When the Hanuman was borned he was very notorious or naughty . He was bothering everyone with his mischievous . His mother was worried . She was told by one rhishi , that when Hanuman will meet Lord Rama , he will turn around , will become devotee of Lord Rama and will calm down . In my view Hanuman represents our mind , which very active and moves from one object to other , just like the monkey . So the Hanuman represents our mind . When we concentrate our mind on the God , then the it quietens down . So when we 'meet ' Lord Rama then we stop being notorious , and become the devotee .
   The 40 shlokas start with a 'doha', may be called a mini prayer. It says that the feet of Lord are like lotus and the dust from them is like pollens from the lotus. Let these particles of the dust , clean the ' mirror ' of my mind .(that is why I pray ) . I will describe the success of the lord Rama , who can give all 4 fruits of action .(FAL CHARI--4 fruits are DHARMA , ARTH, KAMA , MOKSHYA--RELIGION, MONEY, FAMILY LIFE AND ETERNITY OR RELEASE FROM THE CYCLE OF LIFE AND DEATH ) I am aware of the fact that my (physical ) body is stupid, I do not have intellect.So knowing this I want to think of lord Hanuman .I pray to him that he would give me the strength, intellect , and the knowledge.
    I will start with the meaning of 40 shlokas in next blog .

Friday, December 14, 2012


    We as physicians are often blamed for being late , and many a time rightly so . It is amazing that we can do things that well without in trouble. Sometimes I go to see patient and he is in CT scan . Then he or she may be in endoscopy or surgery and then we have to come back sometimes in few hours. One time I was consulted for a patient who after open heart surgery to replace a valve and he had 'air embolism ' . He was still on respirator . As such I was not going to do much except to make sure that the oxygenation was adequate . But when I went to see patient, he was in a hyperbaric chamber . The treatment for the air embolism was to give oxygen under high pressure . This would help to absorb the air that went in the blood .This was to be given for 12 hours or so .There was no way that I could wait in the hospital till he came out of hyperbaric chamber. So sometimes it is impossible to be always in time .
    But this is a different story , where I was not that late .
    It was Wednesday . I have morning hours . I  see patients between  8 am to 12 noon . But it never ends at 12 noon I end up with double bookings and then by the time I am done it is 1 pm or so . So I like to move . As much as patients hate the doctors being late , I hate patients being late . If patient shows up late then I have a difficult time adjusting to the schedule . On that day I was doing fine . I was in time , there was not much double booking and so I was only 15-20 mins late . Then it happened . The lights went off . The power was gone and so the computers were gone and the phones were dead . How dependent we are on these modern things . We did have our printed schedule ,so we knew the list of the patients . One of my long time patient was my next patient . She was never 'no show ' . I was surprised when she did not show up . But I was too busy , to think about it . We had opened blinds ,and were using cell phones. She showed up about one hour late . We still did not have the power . She was put in the room . My secretary told me that she had an accident and she was shaken . I went in the room . She looked OK . I asked her what had happened . She told me the story . About a block from my office she lost the control of her car and hit a electricity pole . Then the police came in , the report was made and so she was late . Fortunately  she  was not hurt.The pole that she hit was the cause of we loosing the power !

Friday, December 7, 2012


   I often say that one does not have 'choice ' in determining when one is born , and when one dies . One does not have choice in determining as to who are his parents . In a way this accurate and to some extent it is good . But one can argue that sometimes one can determine the time of death , as in case of suicide . But I am talking about normal , natural death . But in medicine I have seen that sometimes patients can decide as to when they want to die .
    I had known this patient, Mary for long time . I treated her husband too . He was much older that her and one day he died in the hospital . He was also my office patient . So he had an appointment with me in the office that was made long before he was admitted to the hospital.. Unfortunately my office did not cancel it , in the computer and ended up calling his home to 'confirm ' the appointment . She was quite mad , as we did not 'know 'that he had died . I continued to treat her for her asthma.
    One day she was admitted to the hospital . I was called in to manage her asthma . She was not feeling good and was having very vague symptoms . She low grade fever , that many times could not be confirmed , as she would 'feel' warm and hot , but the temperature was normal .She also would have sweating and had some issues with the weight loss , which was not major . The family doctor and the infection disease specialist had done the work up and did not find a reason and felt that it was due to menopause . According to her she had menopause many years ago and these symptoms had started only recently . I was not too sure as to the cause of her complaints and her lungs were 'fine ' . I was little concerned about the possibility of a occult "lymphoma " , a lymph node cancer . (the cancer can spread to the lymph nodes , but when the lymph node it self starts the cancer it is called lymphoma . ). I did do the CT scan of the abdomen and there was some abnormality . I decided to call a surgeon and he opened her up and found out a tumour called CARCINOID . This tumour is one such tumour that can be called either 'a benign tumour that sometimes spreads or metastasises ' or it can be called a cancerous tumour that grows very slowly and rarely metastasises . 'It also sometimes can secrete chemicals that cause the symptoms that Mary was having . Mind you this happened about 22 or 25 years ago . At that time specific type of  scanning for this type of tumour was not there.
    She was cured ! (she did get similar symptoms latter on and we could not find source of any recurrence , but she did respond to the treatment of carcinoid  with drugs .) This turned around her feelings about me as a doctor and I was the only doctor that she trusted . Our relationship continued to grow as I saw her for several years . She was admitted to hospital with asthma and continued to have some fever . The primary care doctor treated her for 2 days and then called . I told her that most likely her fever was due to urinary tract infection and not lung infection . So I changed her antibiotic and did urine culture and it did come back positive for the bacteria that was not sensitive to the antibiotic that she was getting before I saw her . (though it was good antibiotic for bronchitis . )
   Next time she was admitted she had lower back pain and the doctor suspected urinary infection . The urine culture came OK and then I was called in , not because of lung problem , but it was a consult at her request . I found out that she had fracture vertebra and it was due to osteoporosis and had her do procedure , where they put a glue or cement . Her was 80 % gone . Again I was the hero .
   I continued to see her in the office . She was almost ninety . And she was admitted to the hospital . Had bad bronchitis, pneumonia . She also had bad heart for last 5 years and had irregular heart beats . Interestingly she had avoided being in the hospital in spite all these problems for last 3 years . I started he treating her , so did the cardiologist . Nothing had changed much in cardiology part , but I was quite limited in treating her for the lungs as her heart rate was continued to be a problem . She was not bad , but did not get better as was expected .On 3rd or 4th day I went to see her in her room . The nurse was with me . She was on medicine for her heart rate , but it was still up . She was awake , alert , fully oriented , was not in distress , but was quite congested . She was unable to cough up . I examined her and was talking to the nurse about change in her treatment , she stopped  me . She took my hand in her hand and said , "Doctor , how long we have known , each other . ( it was not a question but a statement .)There is no one that I trust more than you and I will really miss you . but it is time to depart ." I understood what she meant . She continued . " Please let me die peacefully . I just want to be comfortable ."
     I called her family , made her DNR , stopped her all labs, x-ray and work up . I did not stop her medicine. She died in less than 24 hrs !!!!!
  I do believe that the out of all our attachments in this world , (eating , sex , music drug addictions , ) attachment to the body or to 'live ' is most powerful and we can rarely get away from it .

Friday, November 23, 2012


    I have often said that treat patient as a patient , not only from your speciality stand point , but as a patient , who has medical problem . We all sub specialist are physicians first and specialist or sub specialist latter .We all do medical training , first as Internal Medicine ,so we should be in position to diagnose , if not treat everything in an expert way . We may not know be in position to know all the details of the treatments of all the diseases , but we should be in position to help diagnose . The case that I am about to tell is one such case .
    I had known this 70 years old patient for few years . I had diagnose him to have a lung cancer . Fortunately for him he was operable . We were in position to operate and resect the cancer . I did continue to see him for a while . He continued to do well and was followed by Cancer doctor , an oncologist .
    When I saw him after a gap of 2 years , it was because he was short of breath . It had started suddenly and his oxygen was low . I saw him and did CT scan . It surprisingly showed a metallic object in right bronchus . He had lost 2 lobes out of three  lobes . So he was left with only one lobe , which was blocked by something and so he was short of breath and oxygen was low . I did a bronchoscopy    and saw the obstruction . IT WAS A PILL .I tried to take it out , but was unable to do so with his oxygen dropping . Finally we had to do it under anesthesia . .He did well and was discharged . I saw him once in my office . He did not see me for almost more than year and a half . He came to office as the oncologist had done a CT scan and it showed fluid around the lung . He was mildly short or breath. On examination the lungs sounded clear . There was mild reduction of air going in the right lung . The CT scan had shown a pocket of fluid on the top part and 2 other pockets on the lower part .When I started to check his blood pressure , I noticed that his arm was swollen on left side . I asked him about it . He noticed a week ago and it got gradually worse . He had kidney issues and his kidney function was quite compromised .So when he saw the kidney doctor , he called the cancer doctor and he had test (called Doppler ) to rule out phlebitis or a clot in the arm , that could explain the swelling . It was normal . So then CT scan was done and it showed the fluid and he was asked to see me to take out fluid . I asked him on the cause of the swollen arm , and he did not know . I asked him if any other test was ordered , to find out the cause of it ,he said no . I was surprised.I was not sure what was the cause of the swelling, but suspected that there must be a blockage to the blood flow return deeper that what was tested . But I was not sure why  there was no swelling of the right arm as the deeper structure called SVC , drains all the blood back from both upper extremities and head . So if it is blocked , why there was no swelling of right arm ?
    I called a vascular surgeon , but when my secretary called the office , they got appointment after 3 weeks . I called a cardiologist , who does vascular studies , but he was out of town . So I called his associate and he agreed to see the patient . He saw the patient and did the Doppler of the same left arm and did echo cardiogram . He told him that his heart was OK and the swelling was not due to heart and may be due to kidney problem . I was not happy . I called a radiologist who also does lot of vascular interventions . He was very helpful . I told him that I was suspecting the blockage of the SVC .He looked at the CT scan that was done earlier and told me that my hunch  was most likely correct .. Unfortunately he could not do the study and treatment on Friday . I decided to admit the patient on Sunday and he agreed to do the procedure .
   I am glad to tell that the test was done and there was blockage of the SVC and he did stent it and the swelling got resolved in 3 days .
   I had said it in the past , " your eyes can't see what your mind can't think ."Otherwise I am not sure why it took so long and 4 doctors to solve the problem .

Monday, November 19, 2012


   We as physician are asked about the prognosis . This is not a question when we diagnose things like high blood pressure or diabetes or asthma . But when we tell patients about cancer or poor heart function etc , then the question always arises as to what is the prognosis . This goes farther when the condition progresses and when the patient and the family realizes that the things are not going well or not getting better and are not likely to get better. This is the time when patients make decision on DNR. If the END is near then sometimes they decide to go with the Hospice . But as I mentioned in last blog , when these decisions are not made in advanced or they are made but we as doctors are not made aware of it , we end up having a mess . Once is patient is put on 'life support ' , taking him off is little difficult . There are state laws and regulations and there are hospital rule and regulations .When we have to take patient off the life support , it is called 'withdrawal of life support ' . In this process there must be an agreement between patient or his representative , and two doctors about the prognosis and to stop the futile efforts . If patient can not make decision (which is the case most of the time as he is on respirator and sedated ), then we have to get OK from his relatives . If patients have made decision about their representative it is easier .If there is no written representative , then there is rule as to who can make decision . The spouse is first in line , then children , then the parents and lastly siblings.The problem is when there are more than one child . The law needs 50% plus one to agree on the decision  to withdraw.So if there are 3 children then all must agree .(one and a half plus one ).
    I face this situation frequently in Intensive Care Unit . It is easier to make decision when we know patient or there is really terminal condition or condition is terminal . e.g. brain bleeding . But then there are times when it is not that clear . When a physician signs a form stating that the " condition is terminal and recovery is unlikely " he is acting as God . In my life time there may have been two or three cases when I have postponed the withdrawal for 24 hrs just to get a chance to wean down or get more evidence that with or without treatment patient will die . This has sometimes caused some friction with the family or other physician . I have weaned off some patients of the life support and avoided making decision as God .

Sunday, November 18, 2012


   We often talk about the 'living will '. The hospitals are required to ask every patient that comes to hospital if they have 'living will ' . The lawyers also do living will as part of estate planning . But no one talks about DNR. Many years ago I read an article written in  a medical gernal by a Harvard doctor (not medical doctor ) . It criticised medical community for not 'honoring 'her mother's 'living will ' and how she had to go through suffering . I was shocked that this Harvard professor was not aware of the difference between the meaning of living and the "true' DNR . Unfortunately this confusion is very common and it leads to more problems than help medical community .
    The living will states that "if my condition is determined to be terminal -----". So determines that the condition is terminal or not ? In the article that was written by the above mentioned professor, her mother was admitted to the hospital with the living will and in the middle of the night had a stroke . She was not breathing well , so the doctors decided to put her on respirator. This was done as a emergency decision in the middle of the night . The living will stated that she did not want to be revived ,if the condition was determined to be terminal . There was no way to know at that time in the middle of the time to state confidently that there was no way that she was going to survive or die .So the doctors had to make quick decision and they decided to put her on the respirator . If she would have recovered from the stroke then the decision would be applaud to be great , but when she did not improve then the decision was "wrong " and did not "respect her wishes " . per the author. This reminded me of one of the patients that I had seen .
    I was called in to see this patient .He was admitted to Intensive care unit . He was brought to ER with decrease level of consciousness.He was not breathing good , so was put on the respirator .When I saw him in the ICU, the nurse told that his wife was there , and was very mad .I saw him ,he looked OK and everything looked OK .I was not too sure as to why the wife was mad . I did not know exactly what made him sick . But he looked to be getting better . I asked her many questions ,and got the history . Then I came to know why she was mad .She had brought with her ,his living will 'Her point was that he had living will and the doctors in ER still put him on respirator . She was so mad that she told me that she would be 'suing'the doctors and the hospital . I explained her the situation and told her that he was doing quite well and I expected him to be off the respirator in next 24 hours . He was quite obese male , though young and most likely had 'sleep apnea ' . He also had what is called as 'obesity hypoventalation syndrome . ' This in past was also called Pickwick  syndrome , based on a character from a novel written by Charles Dickens . In this condition patients do not respond to carbon dioxide retention . Normally we have to main stimuli (to our respiratory centers )to breath , One is lack of oxygen and second is build up of carbon dioxide . (there are other stimuli too , but these are main ones in day to day life . )So these patients are very sensitive to sedatives and narcotics . I was not too sure what might have have happened, but my thinking was that he stopped breathing when he was given oxygen , which took away his stimulus to breath as he did not respond to build up of carbon dioxide . Anyway he did well and was taken off the respirator . He was discharged on 3 rd day . After he was taken off the respirator , I did call his wife and asked as to how she felt NOW , about the decision made by the ER doctors in spite of his living will . She was off course very happy .
     The living will is not as great a paper as it is made to be . It does convey the patients thought process about life in general . But one wants to be not put on any artificial life support under any condition , then he or she should consider DNR. . So it is not left to the doctor or paramedic or to the family members, who at times are left with guilt feeling . This is so important in patients who are very old or have end stage disease, like cancer or very bad lungs or heart or have dementia , in short quality of life is very poor .

Thursday, November 15, 2012


   I told you about the story of patient who came with testicular torsion , and was dressed up like a female . This made me think for a different diagnosis, as I thought that 'he ' was 'she'. He was dressed up as female due to 'nessecity '  and not as choice . The story that I am going to tell is of different kind.
   I saw this white male 75 years old . He was admitted to hospital with pneumonia. When I saw him he was in his room , with his wife and was in hospital gown . After taking the history and and talking to him and his wife , I felt that he was aspirating . Aspiration means food or liquid instead of going in to stomach ,it goes to lungs . This can happen after stroke or as some people get older . This is due to poor coordination of swallowing muscles.So I ordered the swallowing function test . This is done by the radiology and speech therapy team . It confirmed my suspicion . He was grossly aspirating and the speech therapist felt that he should not be allowed to eat , but should get a feeding tube . This tube is inserted in the stomach , and then patient is fed with a liquid like Ensure or Boost etc . I spoke to them and they agreed for it , only me telling them that this could be temporary . The plan was to do the stomach feeding tube  and then repeat the swallowing test in next 2-3 months .The he had the feeding tube inserted . His pneumonia was getting better . One day I was quite busy and could not see him in the morning . So I went to see him in the evening . He was not in the room . So when I asked the nurse as to where abouts of him , she said that he and his wife were walking around in the hallway . I went to see him and when I saw him I was surprised . He was walking with his wife , but he was wearing female night gown . i was not too sure as to why he was wearing the female gown . I asked his wife latter on . The answer was perplexing . He wanted to be a female at age 72 or 73 . and had told this to his doctor . He had also told this to his wife and it seemed like she had no objection . He was also prescribed female hormones to reduce facial hairs and develop breasts.
  I did see him in my office . He did come in femenine clothes . He still had aspiration , though it was little better . He did not want to continue the feeding tube , so we compromised . He was allowed some 'forms ' or 'consistenct ' food with reduced risk and he was also fed via the stomach tube .  He was diong this as his choice.

Monday, November 12, 2012


  I have seen many surprises in my medical life , but certain things one expects from certain age groups . I would not expect hardcore drug addiction in older patient ,At the same time I would not suspect cancer in younger patient . But things are not always that clear cut . The two short stories that I am going to tell , belong to such category .
     I was working in ER many years ago . It was late at night . We used to have 2 residents working in the ER , but after 1am or so if the ER was not busy , then one resident would go home .On that day I was suppose to stay till  morning .At about I was told that there was a lady who had come with 'lower abdominal ( belly ) pain '. So I went to see her .Normally at such odd time two types of patients come in , those who are so bad that they can't wait till AM ,or those who have no time otherwise to come to ER at other time .
    When I entered the room , I saw this young lady . From her dress I would have suspected that she was a prostitute .Her make up , her flashy dress was indicative of that . The first thought that came to my mind was that if she had lower abdominal pain , the she had gynaecological problem , called PID, pelvic inflammatory disease . In our ER we had separate Gyn ,resident. But I had to make sure that there was no medical cause of her belly pain . So I started asking questions . So where does it hurt,? I asked 'Down bellow '. 'Down bellow , where ' I asked . The answer was shocking . He said , 'Down bellow in my balls " I did not understand , So (s)he pulled pants down . She was not 'she ' but she was 'he'. He was pretending to be a female , so as to get 'clients '. He also was taking hormones , estrogen to get enlargement of the breasts  He did not do any sex change as he was not transvestite . When I examined him he had testicular torsion , twisted testicle , which can cause severe pain and needs quick surgery . Needles to say I called urologist and he was taken to the surgery .and did well.My other story in next blog .

Sunday, October 28, 2012


   I have a ring in my index finger. This is rather uncommon finger for having ring for Non Indians . Many of us know about the significance of this ring , but I do get questions asked about this . This story is one such story .
   I was seeing a patient in my office . I was seeing this patient , whom I had seen in the hospital for asthma. She was doing fine, and had come for the follow up after the discharge .After I talked to her and examined  her ,I told her to wean down the medicines that we had started in the hospital . As I was writing the note , she asked me about the ring in my index finger . I answered that it was a ring with a stone ,that was suppose to Planet Jupiter stone . Since the the mount of Jupiter is at the base of the index finger , the ring with the stone of Jupiter should be worn in Index finger. (This is based on palmistry .) So then she asked me if I believe in " these kind of things "I said yes , as otherwise I would not were the ring . I took out my ring and showed her how the stone touches my skin .
   Here I must explain you some other thing . Many months ago , may be 6 or 8 months ago , when I was making rounds at the local hospital , I noticed that one of the nurse's aid was awfully quite . She was Guinness lady and must be Indian by ancestry. She was also Hindu . So I asked her as to why she was quite . She asked me if I had read the news paper . It was Saturday and I had no time to read news paper before I could finish the rounds.So then she told me the story . There was a story about a women being killed early in the morning . The woman came home late at night from her job and as she was getting out of her car 3 people hit her with a gun and when she felt unconscious, they ran her over with her own car . They were caught soon and one of the 3 people was her 18 or 19 years old son . At that time I was trying to learn reading of horoscope or natal charts. So I got the boy's date of birth and place of the birth and sent it to some one in India to read the horoscope and tell me what was his 'fate '.
   So when this lady was asking me about my belief in horoscope , I thought that story . I had not gotten any response from India . I did not want to be too specific . So I just told her that one of my friend's son was not behaving  well and was in trouble with the laws, and I had sent his horoscope to   India to see what was his future. I did not tell her about the killing , nor did I tell her that he was in jail . The story was quite old and nothing was mentioned in the news papers .
    She looked at me and said ,"do you believe I am psychic ?" I did not know what to say . (may be she would read my mind without me saying anything ?). She continued , "Please tell your friend that his son is in bad company , but do not worry , the judge will find leniency. "I did not say anything .
    Another 6 or 8 months went by . The case was finally in the courts . The 18 tears old became the witness for the prosecution and had a deal . He was given 10 years . He would be free by the time he is 28 or may get less imprisonment for well behaviour .
    The patient who claimed to be psychic was right .

Saturday, October 20, 2012


     I was watching the major debates between the 2 parties ,since this the 'season 'for it , and I was struck by the fact that quite many people are not aware of the changes that have occurred in last few years. I was talking to a family member of one of the patients , who happen to be a lawyer and a Democrat. When I told him  certain  changes in the practice of the medicine , he said , 'it is not possible , you are making it too simple .' After listening to his comments and then listening to many of my friends , I was stunned by the misunderstanding that exists. So I decided to write this blog . I am sure that lot of people will find it difficult to believe , some will feel that I am totally wrong, and some will feel that I am ignorant, rich person with ' no heart '.
    Let me start by saying that I am in practice of medicine for very long time  and I 'understand ' it very well . An average doctor has 4 years of college , 4 years of medical school and the extra years depending upon the speciality . Family practice or Internal medicine doctor will have 3 more years. If one does Cardiology or pulmonary etc then they have additional 3 or more years of training . I feel that  a ' college graduate ' should get more salary than a 'high school graduate ,' and a person with doctorate should get more that person with simple graduation, if they are in same field . And normally we do see it in life . So my feeling that sub specialist , who has extra 3 or 4 years of training than a family doctor should get more reimbursement than the family doctor and a family doctor who has 3 years of extra training than a medical graduate should get more money is natural. In last 2or 3 years ago this got changed . Now a days a doctor who has done 6 or 7 years of training after medical school , gets same money as new graduate from medical school who has no extra training. Does this sound right?So spending these extra years has no 'value ' per our government .
     Let me tell some other changes . If I had seen a patient in November of 2009, and then he did not come to see me till October of 2012, I have to charge him as 'follow up' visit, even though I will have to get detail history as to what has happened in last 2 and 1/2 tears . I have to spend much more time than usual follow up patient. I can not understand the thinking behind this 3 year rule .
   In 2012, they decided that all the doctors who treat patients with medicaid will need to be 'finger printed '. The original rule was that this must be done every year , as if the finger prints change . I did my finger printing more than 6 months ago . I am still not approved, and I have been participating in medicaid , even though the reimbursement is very low , for last at least 25 years. So till I get approved I am not getting paid for seeing patients with medicaid.This is how government run managed programs work.
.     Per new ACA (Obama care ) one should be in position to find health insurance for 8% of their income . So for a secretary making $30,0000 the premium should be $2400 per year or $200 per month . Per our experience premium to get $500 deductible policy is $300 or more . So if I have to provide health care  for my employee,I would ask these employees to go to the government pool . NOW think about it . What kind of health insurance one can get for such low premium?. It would be such that the befits would be low , so low that no one would accept it and then many of these patients will have to go to ER. There will be longer wait and more expense as the ER doctors do not know the patients.
    I was told that if one put a frog in boiling water it would jump out . But if one puts a frog in water and slowly heat it , the frog would not jump, but will get cooked . I was also told that if you want to 'enjoy ' the food in a restaurant , then you should not go in the kitchen . This applies to our taxes and government spending . If  you are approached by some one that you know ,and ask you to 'give'money as he wants to buy a new car, would you give it ? I am not talking about a loan but just giving it as a gift . The answer is  going to be no . So if you would not 'give' a gift to some one you know , why would you give the gift to some one you never met ? But this is what exactly was the "cash for clunkers "program. The government took money from the tax payers and 'gave' to people who bought new cars . If one is spending money for himself, then he is very careful , if one is spending his own money for someone else ( buying gift ),he is less careful. and when one takes money from others and spends it for still some other persons then he is not careful at all . The government spending comes under this 3 rd category.So money is wasted and the programs are not efficient.
    There are ways to stimulate economy . I was asking this to one of my patients . Now a days one can buy a condo for $50000.  which was sold 3 or 4 years ago for $200000. But the banks are not giving loans due to significant rules . So only those people who have money can buy it . But these people have no 'tax incentives ' . When one buyes a real estate, there is realtor, closing agent ,title company etc, they all will get work and benefit . If the property needs fixing, then handy man , carpet company , and many others will find jobs . So if these (rich )people who can afford to buy these condoes,  are given tax incentives  they will buy it and many more will get the jobs . This the domino effect . There is no question that the person who buyes the condo will make profit.But at the same time many are benefited .
   There are solutions to health care too . I have written some of them in my blog on Health care .

Saturday, October 13, 2012


   Quite often we see bad things happen to good people. Many years ago my professor of preventive medicine , had heart attack. When I went to see him in the hospital , he asked me as to why he got the heart attack. He was not a smoker, did not drink alcohol, was vegetarian and did not have high blood pressure or diabetic. His cholesterol was normal and he did walking as exercise daily. So this professor of preventive medicine was asking me as to why "he " out of all the people got the heart attack. Now we know few more factors that predispose to heart attack.But the the medicine is like the story of 7 blind men and the elephant , each one of the blind men was touching the different part of the elephant and 'feeling ' that he knew how the elephant really looked like .So as we know more , there is more to know . So the question that my professor asked me is not uncommon . I get it for many diseases, and under many circumstances. When I am asked why do I have asthma , I ask if anybody knowes why people get high blood pressure or diabetes. WE DON'T KNOW WHY WE GET THESE DISEASES OR FOR THAT MATTER ANY OTHER DISEASE. Not only that we don't know why we get them (other than statistical data as to who is predisposed to them ),but we never 'cure' them , we only 'controll' them . That brings me to the today's story .
      I saw this young 28 years old male for pneumonia. He started with symptoms like cold . So he went to a walk in clinic . He had an X-ray and was told it was OK , He was given an antibiotic and cough medicine and was sent home . He did well for a day and then the fever came back and cough got worse . So he came to the emergency room .The new X-ray done showed pneumonia and small amount of fluid around the lung .He was admitted to the hospital.When I saw him he was quite stable. He needed
some oxygen .The fever had gone down .We had started him on antibiotics and he was doing better.
    We continued to watch him . On 3rd day we did a new X-xay . It showed that the fluid around the lung had increased . I did a CT scan . It confirmed the pneumonia and the fluid . So I decided to take out the fluid as it could be infected . The small amount of fluid is not uncommon with the pneumonia.But if it increases then it could be infected or just because of the amount of the fluid , might necessitate draining it .When I did try to take out fluid , it was pus. It was so foul smelling that smelling it might make one feel dizzy.I did drain some , but I knew that he would need surgery. We called the chest surgeon. He had surgery and did well . When I saw him next day , he was doing well. He asked me a question , "Why did I get it . I don't smoke and hardly drink, I don't do drugs . When I got sick , I did see a doctor. So why is it , that I not only got sick , but even needed chest surgery."
  I had no medical answer. But being firmly believing in the law  of karma ,I had to explain him the philosophically reason. So I started to explain him the karma and how it is stored, and how each karma has to come to fruition, and must come to fruition. Unfortunately, we don't know the 'deed ' that we did has caused the miseries of today.As I was explaining him ,his church priest came in . I continued to finish my thought.and left.

Wednesday, October 10, 2012


     We often have a debate about the cost of medicines and the cost of the health care . There are usual 'punching bags ' for some people, especially the politicians . "The bad doctors " or "The greedy doctors ". But more often it is Drug companies . When we analyse the cost of health care, we realise that the physician's cost is about 15%, the cost of hospitalization is 70 % and the 'evil' drug company contributes 15 %. So why are they vilified and the patients believe in it ? The answer is simple . The patients never see the cost of hospitalisation . The medicare or the insurance company pay es most of the expense. So even though at times it is outrageous , patients don't realise it . To take an example , an endoscopy --EGD, --to look inside the stomach , the doctor who does it and does biopsy and analyses the finding and treats the disease, makes about $150.The hospital charges are about $1500 to 2000 or more depending upon what anesthesia was used. The pharmacy cost known to patient as they pay it at the pharmacy and many pay it from their pocket . I am not defending cost of the medicines . I do believe that it is too high . The story that I am telling is one such case.

        I saw this 64 years old female who was seen by me for pneumonia and chronic cough . She was seen by another lung specialist , but her cough had continued and so she wanted a different MD.I saw her and saw her X-ray I did not like it . I ordered a CTscan . It showed a mass in the center of the left lung. It was somewhat hidden and not obvious on plain X-ray as it was close to the big blood vessels and the center. I did bronchoscopy and diagnosis of  the cancer was done .It was not surgically resectable . So I consulted the radiation doctor and an oncologist .The radiation doctor felt that she would be best treated by chemotherapy. The type of cancer was such that ideally is treated by chemotherapy and not by radiation . The tumour was pressing on the bronchus and the artery going to the lung, So I had called him . The patient was treated with the chemotherapy and had usual side effects , but was doing OK .After about 6 months of treatment she was doing fair, but was admitted in hospital with generalised weakness. She was found to have low salt in the blood .She was treated and got better . and was discharged . She was readmitted in 2 weeks and had low sodium again . This was due to the cancer , which secretes some chemicals that cause low sodium . She was treated and discharged again . After 3 or 4 hospitalisations , the kidney doctor gave her a prescription for a pill to help maintain sodium level . She called me when she went pharmacy to get it . The cost of one pill was $250, YES ONE PILL WAS FOR $250. There was no way she could buy it .
    I ended up talking to the radiation doctor and he agreed to give her radiation treatment to the tumour . My simple thought was that the amount of the chemical secreted by the cancer was directly proportional to the size of the cancer . So if we can reduce it , the chemical secretion would go down and the sodium would be better controlled.
   The idea worked. The radiation treatment did work . But I still can't fathom the idea of one pill could cost $250. ( If one drops the pill on the floor he could offer $50 to find it out .)

Saturday, October 6, 2012


     When we learned the pharmacology in college , one of my professors had said that if you write nausea, vomiting , diarrhea etc, you would be right . As I started practicing medicine , I realised , as to  which side effects are common and which are not that common , but can occur.I have often said that if aspirin would come out as new medicine today , FDA which approves or disapproves the new drugs, would not be approved .Aspirin is one of the miracle drugs, just like statins , and has many benefits, but due to reported side effects it may not be 'safe ' per FDA criteria . Some of the rare side effects we learned with experience. Today the computer raises 'red flag ' with all most any 2 drugs , and then we have to check out if the drug interaction is major or not.But to know if there is any drug side effect from the drug , one must know that what drugs patient is on .This may sound like an easy thing , but in practicality it is not . Many patients describe their medicines as "blood pressure pill " or that 'red color small pill 'or the" one that I got at CVS pharmacy " etc .There are patients who do come out with a computer print out of their history , list of medicines. This help a lot .
    But there are incidences when even if  we try , we either don't have full list of medicines that patient is on or patient forgets some of the chronic medicines . The story that I  am about to tell is one such .
     Mary was refereed to me for complains of cough , which had started about 4 or 6 weeks .Her primary care physician gave a course of an antibiotic, and a cough medicine. It did not help much ,So he did a blood count and a chest X-ray.The X-ray showed that she had 'pneumonia ' . So he gave her another course of antibiotics. The cough continued. Now she was short of breath . So now she was referred to me . I saw her in the office . She was 74 years old white female , who had history of high blood pressure . There was no other major medical history . She had had hysterectomy and some arthritis . Her examination showed that she was mildly short of breath with the walking and her respiratory rate was 20 , little higher . She had some rales on examination of the lungs and her oxygen saturation was slightly low at 93 %.I saw her X-ray. She had diffuse infiltrates in both lungs.I decided to do some blood tests. Her previous X-ray , which was 6 months old, had shown the lungs to be clear.I also decided to do the bronchoscopy . I did the bronchoscopy , My main concern was some 'unusual infection' But I was not sure why would she get it . ( She had no other history that could make more susceptible to infection ).
    The bronchoscopy did not show any unusual infection . The biopsy that I had done showed only "inflammation ". I had called her for the follow up . I still had no specific diagnosis . My options were limited . One was to do open lung biopsy, or the other was to take' chance ' and try steroids. She was very reluctant for the open lung biopsy, which was a major surgery. I was talking to her about trial of steroids . I went over with her the use of steroid , side effects etc .I again wanted to know her medicines , so I would know if there was any other 'risk ' of using the steroids in this elderly lady . They were same as I had noted in my first visit . Then the daughter said . " mom did you tell the new antibiotic that gynaecologist added 2 months ago . Are you not taking it ?I don't see it on your list. "Her answer was "I forgot ".I asked her the name of the antibiotic. The answer I got was the 'Answer ' that I was looking for . She was taking an antibiotic , called nitrofurentine . This is used to prevent recurrent urinary infection. This is given on long term , which means it is continued for months .This antibiotic can cause an 'allergic' reaction in lungs , which causes inflammation and can lead to scar tissues .
      I told her to stop it . and started her on steroids . I saw her in 10 days . She was 80 % improved . I did new X-ray in 3 weeks . It showed 'marked improvement'.So we were on right tract .
      If we had not known that she was on this nitrofurentine , and it was not stopped , she would have been worse.So sometimes we need little luck .

Tuesday, October 2, 2012


  We often say many stotras . It has happened to me that I learned some of them  by listening to them . So I often misunderstood them, said them incorrectly and did not understand the true meaning . One of the 'ARATI', that we Hindus do , is often said in a wrong way . It is not in English , so those who do not understand the language will have difficulty in understanding it . But I will state it for making a point . It is
 " sukhakarta dukhaharta,warta whighnachi,nurwi purwi prem krupa jayachi." I have written it in the way that we say it . The meaning from this is not accurate . The correct way of saying is "sukhkarta dukhharta ,warta whignachi na-urawi( nurawi ),purawi prem krupa jayachi."Now that one makes perfect sense .
     The Ganapati Atharwashirsh is one  which has a great meaning . It was written by sage Atharwan. Every one of these stotra start with OM. The OM has three letters, namely A, U ,M, which represent 3 deities ,the Creator Brahma, the sustainer Vishnu and the destroyer Shiva .So we start with the OM ..So now for the meaning
of the whole stotra.
     I bow down ( do namaskar ) in front of the GANAPATI--the lord or in charge of the GANAS the soldiers of the God.You are the Lord which we can see with our eyes . You are the creatore of the entire universe .You are the sustainer of the universe. You are the destroyer of the universe.You are the 'real' Brahma or the pervading consciousness. You are indestructible Atman.(not limited by body called Jiwatma but Universal Atman called Parmatma ).
   I will tell the Truth,(so) you protect me .Protect the one who is describing( your real description).Protect the one who is listening to this (description )Please protect the teacher who is giving this knowledge and one who is receiving or learning it (the Guru and the Shishya)Protect from east , protect from west , protect from north protect from south, protect from  top , and from bottom .Protect from all sides and from all things -dangers .
     You are the speech(one that is written and read ).You are the Knowledge. You are the Bliss, You are the Brahman.You are the Truth, the Knowledge and the Bliss.You are the One.You are full of the knowledge and you are full of any special knowledge .
(knowledge is in general or understanding of the God and specific knowledge is that what we want to know in our day to day life .)The entire universe has originated from you .You are the the reason why this universe continues to exist, and this universe will end in you. You are the 5 big elements , the earth , the water, the fire or energy, the wind and the space .You are the 4 different parts of the speech . (called Para, Pashyanti, Madhyama , and waikhari, The last one is what comes out as the speech . But there are 3 other stages that we go through before the actual words are pronounced called Waikhari . )You are beyond the 3 qualities(Gunas -Satwa, Rajas , and Tamas).You are beyond 3 bodies(physical, astral and causal called Sthool, Sukshna , and Karanmaya).You are beyond 3 Times --past , present and future.You reside in Chakra called MULADHAR .You are the 3 different energies or the powers, ( strength of desire, called Ichchashakti, the strength knowledge called dnyanshakti, and the strength of the action called Kriyashakti.)The sages are in trance of ( thinking about )you are the creater called BRAHMA ( different than Brahman), the sustainer Vishnu and the destroyer the Shiva., You are the Indra ( who is the king of personal gods and who enjoys the pleasures of the creation . )the Fire (that receives the sacrifice in the Yadnya ).You are the air (that is needed for survival of entire life -plant animal and human beings . )You are the SUN ( whose energy is needed for the world to continue to  be ),you are the Moon (which is needed for the plants to survive ),You are the reflection in all the living beings (called the Jiwatma ) and you are the pervading consciousness in entire universe called Parabrahma.
   Now there is description of what is called BIJ mantra . Bij means seed . So this mantra sows the seed for the prayer . Take G from the Gana (the army solders . The in charge of Gana is GANAPATI ), Add A to it , then ANUSWAR pronounced as m, then add OM . This OM GAMM IS THE BIJ MANTRA .This is repeated for the understanding and told that by saying this we will get to the lord Ganesha.Ganpati is the Knowledge and this the poetic way of saying it .(OM GAM )The 8 letter Ganesha mantra is OM GAM GANAPATAYE NAMAHA.The Gayatri mantra for the lord Ganesha is similar to every other Gayatri mantra ."We know the appearance of the Lord with one tooth, we think of the Lord with the Trunk ,so that lord should guide us, )
    One can not easily meditate on 'spirit' without specific appearence. So His appearence is described, for us human beings to contemplate upon .(Saguna vs Nirguna )

Saturday, September 29, 2012


     We as human beings often wonder about the life and death.We can neither predict the 'time ' of birth or the time when someone is going to die.So we talk to fortune teller, horoscope reader and palmist, and so on . Sometimes we see people who should not be alive , live for long time , and those who should not die , die . So how is our "life " or to be specific duration of life determined ? There are many explanations.Some are so called scientific and some are philosophical. We sometimes say that the life is a wound up spring and when is is done unwinding , then we die . Then there is theory of reincarnation . We are born with certain seeds of 'karma' which will come to fruition in this life . Then there are some 'karma' which are added , that will come to fruition in this life . e.g. we ate too much or ate spoiled food , and we get sick . So when these karmic effect is done with, we die . This can be compared to annual plants , once they are done with flowering, then they are done .  So in my practice of medicine ,when  I  come across some patients those who should not have 'survived  ' but survive,  this law of karma comes to my mind . Only question sometimes remain is what is it that they are waiting for ?
     When I saw Dorothy, not her real name , she was 70 years old female who was some what short, fragile lady . She was accompanied by her daughter . She was a smoker and had emphysema . She was short of breath walking few feet . Many of my patients are similar or have very similar history . The reason I remembered at that time was that she was married to one of my patients, who also had emphysema and he was smoker too . This also is not very uncommon . Only unusual thing was that he was only 52 years old . So there was a difference of 18 years . She had  bad lung disease, needed oxygen , which she would take off when she would smoke .She was admitted to the hospital several times , During the work up one time , we did a CT scan of abdomen and found out that she had a aortic aneurysm. It was not very large , but needed to be watched . There was no way that she would be a good surgical candidate , so this was the only option .
   She continued to do OK , had finally quit smoking .and had reached 72years of age . She was admitted to the hospital .She was short of breath,and had some belly pain . We did CT scan of abdomen and found that the aortic aneurysm had increased in size . It was not 'leaking '.I called the surgeon , who had seen her in the past . He came and saw her , The aneurysm had reached such a level that he felt that the surgery was unavoidable . In those days there was no endovascular grafting , which is done now a days . (in this procedure no surgery is needed , but a graft is inserted under local anesthesia . ).He wanted to do the surgery next morning . She was transferred to intensive care unit for the safety reasons . She was scheduled for the surgery next morning at 7 am . I had talked to the family , the husband and the daughter . They understood the risk , but also knew that there was no other option , as we had postponed the  operation as long as we could and now the time had come to do it .
    I got a call at 3 am that night that her blood pressure had started dropping . I knew what had happened . HER ANEURYSM WAS LEAKING AND WAS GOING TO RUPTURE . They had called the surgeon , who had called the operating room . She was taken to surgery in next 30 mins and 'made ' it . She was on respirator ,for long time . We had  to do the tracheaostomy and it took about 4 weeks to get her off the respirator. She still had the trach. and as she was not eating and her weight had gone down to 60 lbs , we did a feeding tube . She was discharged to a nursing home with the feeding tube and trach. I continued to do office follow up . She went home in about 8 weeks . The trach was taken out as her breathing was better and we do take out the feeding tube after about 6 months as her caloric intake improved . She continued to live for another 18 months or so .
     On that eventful day when the aneurysm started leaking and then almost ruptured, she was in the best place that she could be ----the hospital intensive care unit . If she was home or even if she was on regular floor or if we had not done the CT scan of the abdomen , she would have died . And even with the surgery with her overall status she made it , only because the " THE TIME HAD NOT COME "!!!!!

Monday, September 24, 2012


    In practice of the medicine , we often tend to see things that reminds me of the story of ' 7 blind men and the elephant '.I also think of saying in one of the scriptures, which states that the the Truth is one and wise men interpret it differently. I have personally seen this and experienced it too . It reminds me of old story .
     In old days there was a train and it had 4 people in a compartment. There was an old lady , one young lady , and 2 young men . As the train was moving at night , the electricity went off ,and there was transient darkness. At that time there was a sound of kissing and it was followed by sound someone slapping . When the lights came back, the old lady thought that one of the young men kissed the young girl, and she slapped him . That was her truth. The young lady thought that how stupid are these men , I am here and they or at least one of them is kissing the old lady . That was her truth. The one man thought that the other man kissed the young girl, and I got slapped . So all three had thought that they 'knew' the truth.AND The REAL TRUTH was that one of the men kissed his own palm and slapped the other man .
    In medicine we often think that we 'know the truith'. And when the truth is out it comes as a surprise on at least some occasions .The story that I am going to tell is one such case .
    I saw this 67 years old male for cough that was going on for 2or 3 months .The primary care doctor had done a chest X-ray,and it was reported normal. He was treated with antibiotics.He was also give cough medicines and was even given a short course of steroids. He felt little better, but the cough continued . It was so bad that he had blood tinged sputum.So he was refereed to me .
    He was ex smoker and had quit smoking 5 years ago and was little obese .He had no fever nor had he lost any weight. He did have some shortness of the breath. On examination , he had some wheezing and rest of the examination was normal . I looked at the X-ray, and I thought that I saw a nodule in the left lower lobe .I was not sure if it was 'real ' , or I was imagining it .Anyway I decided to do a CT scan and also decided to do bronchoscopy . The Ct scan was a surprise , even I had not expected it . The CT scan showed a mass next to main wind pipe called trachea and it was partially pressing on the trachea. My bronchoscopy was completely normal, except for little bronchitis . I did not not see any tumour, even though the scan had shown almost 4 or 5 cms size mass . I know this can happen. The mass was out side of lung and the bronchial tubes . I called in a chest surgeon and he did the biopsy , which showed it to be the lung cancer .
    So when the primary care MD did the X-ray , and it was reported normal , he thought he knew the truth . When I saw the X-ray and thought that there was a nodule in the left lower lobe, I thought I knew the truth, and 'the real ' Truth was that he had a right sided lung cancer that was not seen in the lungs even with the CT can or the bronchoscopy.

Friday, September 21, 2012


    The other day I was in the hospital and saw that the hospital was asking patients to answer a questionnaire, in which they were asked about the treatment that they got in the hospital . They were also asked to evaluate the doctor as far as communication, care, and if he answered their questions or concerns. I was surprised to see some of the 'good ' and 'caring ' doctors get lower grade . I made a comment , that may be they need to ask extra question, "did you need any pain medication ?" . I hear about pain seeking patients everyday . Fortunately I am not directly involved in taking care of these patients, but do know that these patients do exist and get angry when they do not get the pain medicines.Theses patients will not be happy with the doctors, who would not give them the pain medicines. It is very difficult sometimes to really know the difference between the 'real' pain and just drug seeking behaviour. It reminded me of this patient that I had seen many years ago.
     I saw this 71 years old male with complaint of coughing blood . He was coughing hard and brought up blood tinged sputum. He was given an antibiotic and a cough medicine and was asked to see me . He had X-ray done and it was OK , and so he came to me .On questioning , I came to know that he was ex smoker and had quit smoking 5 years ago .He was retired, and had some cough for last 6 months . He had history of high blood pressure and arthritis . His examination was unremarkable .On reviewing his medicines I saw that he was taking long acting morphine called Oxycontin . I asked him as to why he was taking it . He told that he had back pain and was treated by family doctor first and the when the pain continued , he was refereed to orthopedic doctor . He had some X-ray and was given physical therapy and when pain continued was given morphine . I looked at the chest X-ray and noted some abnormality on the left side . It was close to the heart border. I was not concerned about the hemoptysis, but I was surprised by the back pain in this 71years old who needed narcotics to control the pain . I ordered the CT scan of the chest and also the CT scan of the lower spine .
     I was not surprised when the radiologist called me with 'wet' reading . He had a tumour in the spine and it was pressing upon the spinal cord . He also had a tumour in the left lower lobe . ( He also had swelling of the leg and I had done a scan to rule out clot called phlebitis and it was positive for the clot ).The main concern was the tumour pressing on the spinal cord . I started him on blood thinner and called a radiation oncologist , the doctor who treats cancer with radiation . He agreed with me and saw patient same day and started the treatment without diagnosis of the cancer . Due to the clot in the leg I had to treat it first. ( if the clot is not treated then it can travel to lung , which could be fatal  ) So we decided to continue the radiation treatment and the blood thinner fof next 3 weeks , then do the biopsy of the lung mass . We got the diagnosis of the lung cancer , which had spread to the spine and had caused the severe back pain , which needed narcotic.
    The 'clue ' to the diagnosis of tumour was that he did not look like some one who was drug seeking and  had real bad pain , which needed the narcotic . I was glad that I could differentiate between the two behaviours.

Tuesday, September 11, 2012


      I have known people , that remember their loved ones after their death in different ways .Many have pictures , some have tapes , and many others have different means of remembering them . The story that I am going to tell is one such story .
       I saw this 55 years old male with persistent cough. He was a smoker, 1 pack a day for almost 40 years . He was treated by primary care for a while and when the cough did not get better, he ordered a x-ray.It showed 'pneumonia ' . He was treated with more antibiotics. He did not improve , so was referred to me . His examination was unremarkable, except for some wheezing.I looked at the x-ray. It did not appear like simple pneumonia. There appear to be a volume loss, which means , that the size of upper lobe was smaller , I was concerned about the tumour blocking the bronchus and causing the cough , pneumonia, and persistence of the  symptoms .
      I ordered the CT scan . It did confirm my suspicion . There was centrally located tumour.I did the bronchoscopy. It did show the cancer and biopsy confirmed the diagnosis of the cancer . Due to the location of the tumour, he was inoperable. I did further work up and unfortunately the cancer had spread to the liver . So the only option remaining was to do radiation treatment and chemotherapy . He and his wife were very optimistic . 'We will beat the cancer ' , they told me . The wife was a nurse , and worked at the hospital where I practiced . So she was medically knowledgeable.They had a 15 years old son .
       The radiation was completed and chemotherapy was going on . He had lost significant weight . His appetite was poor and nausea made it difficult to eat.He was admitted to the hospital with nausea and inability to keep food or liquid down .I saw him and knew that it was more than just effect of chemotherapy.I ordered the Ct scan of the belly . It showed the intestinal blockage .I was hoping that it would resolve on it's own , though by looking at the CT scan I knew that it was due to cancer . Since he did not get better, I had no choice but to call  surgeon. He was operated and it showed that there was cancer in the small intestine and it was blocking . The surgery did help and he was better , But the cancer had spread and was worse in spite of all the  treatment .I have seen many lung cancers , but never seen cancer going to small bowel and causing obstruction. I had along talk with the wife and made him DNR . I knew that not much could be done .
      He died in next 3 weeks. I talked to the wife , she was expecting it and took it well
      Six or eight months had passed , I was sitting at the desk , writing my notes . I saw her,the wife . I asked if everything was OK. She said 'fine'. I started talking to her .When it came to her husband , she told me that they had done the cremation . When we talked about the memories , she told me something that shocked me . He had total knee replacement . Before he died he had told her two things . One was to get married to his close friend, who had helped them , including taking care of the young son and second take home the 'artificial knee ' home and' keep it as his memory.'

Sunday, September 9, 2012


     I have always felt that our spoken words have impact . In today's society  we have politician say things , promise things to get elected , and once in power they don't keep any promises , and the we never take them to the task . I have tried to keep my word , with my kids .Otherwise our kids have  have no role model. But even our spoken words can cause impact , and we need to be careful.
    I have had incidences in my life , where I said things inadvertently , without realising the impact of my words . There are several such incidences , that happen to us , but I Will tell you  one or two'
    I had seen a patient in the hospital , for the complaint of shortness of the breath. She was 50 years old female , who had history of breast cancer and came to the hospital with shortness of the breath . The reason to remember her name and the case is due to her ancestry , she was from Guiana and had her last name which sounded very much like one of the Indian names . When I met her husband , I realised that he indeed was 'Indian ' , except that he had no relation to India . His forefather had  or must have migrated to Guiana and he neither had Indian language nor religion or any affinity for India . (I have often wondered about the 'melting pot ' as the US is called and thought about what would happen to my grand kids ). Her X-ray showed that there was fluid around her lung on the Right side . With the diagnosis of the breast cancer , the possibility of this being related to the cancer spread , was quite high . I did do a CT scan and it confirmed the fluid . Under the ultrasound guidance I did put in a catheter and drained 800ml of fluid . It did show cancer cells confirming the diagnosis of spread of the cancer to the lungs . This was not good news . She was on chemotherapy.and in spite of that she had spread of the cancer .
      Normally we continue to treat the cancer in hope of preventing the recurrence of the fluid .If it comes back, then we drain it again or put in a chest tube to drain the fluid and put in talk powder.The talk powder acts as 'glu' and this prevents the fluid from recurring , as there is no space to accumulate . I talked to her and her husband . She was discharged .
    I did a follow up X-ray in 3 or 4 weeks and it did show that the fluid had increased . The time that it took to come back was too short for me to redo the drainage . We need some semipermenent 'fix'. .So I called a chest surgeon . She was readmitted and had the surgery . The talk was put in . Everything went well . She was discharged and was continued on chemotherapy .
     Then it happened . She was readmitted with the shortness of the breath . I had not seen her for the six months. She was doing fine , the chemo was doing OK and they were thinking that all was well . Noe with the  shortness of the breath, she was admitted . I saw her in the hospital . She looked OK when she was sitting in the bed , but least little activity , she got short of breath . Her oxygen level was normal . The x -ray showed abnormality which looked like the fluid was worsening . I did CT scan . It did show some fluid , but it was not 'free ' It had pockets . It also showed that there were tumour nodules on the covering of the lung called pleura. There was no way I could do any drainage of the fluid.So I called the surgeon , who had done the previous surgery , putting in the talk.
      I was not too sure if he could do much . One possibility was that he could go in and 'peal off  ' the pleura .The normal covering of the lung is loose , just like covering of tangerine. So it is easy to peal it off . But in case of the cancer spread, the covering becomes thick  like avocado, not very easy to peal it off .
    I had talked to the husband and told him about the difficulty that we were facing .I was home and was with my 5 year old son . We were watching some cartoons , when I got a call from the surgeon . I was talking to him , and I had forgotten that my son was in the same room . I was under the impression that he was watching the TV . The surgeon had seen her , had seen her CT scan and felt that he could not do much . "Can't do much , she is going to die " , he said . I told him that I had talked to the husband , and will sit with them and tell them that not much could be done and she is likely to 'die' .
       I hung up the phone and looked at my son . He was looking at me , with disbelief . He had heard every word and was shocked that 'his dad ' who is suppose to 'help patients' and 'save ' them was going to let the patient die .

        It took me several minutes to explain as to what was going on .
        My words had impact , without me realising it .

Saturday, September 8, 2012


      I did state about he God particle in past. The so called God particle is the Higgs Boson . I am not sure what it is , but certainly it is not God particle , in sense of it being God , It does not have charge or spin , but has weight . So it may be something that has some quality , and the GOD is 'without any quality'. ' 
      There are 2 other things that caught my eye, one is 'dark energy ' and the other is 'dark matter'. When I was thinking about both of them , I thought of their qualities and if it came close to anything that scripture describes . So let me start by saying that in scriptures , the space was created first, then the air , then the energy , then the water and lastly the earth. Each one of them have quality or qualities of the previous ones .e.g. the earth has all 5 qualities like one can see it, taste it, smell it , feel it ,and here it . The space is not abscence of 'everything' or'' nothing'' .But is something active.  When Hubble was looking at the space , universe , he observed that the galaxies were moving away from us . This was not as much a surprise as was the observation that the distant galaxies were moving faster than the nearer ones . If the distance was double ,then the speed was double. e.g. 100 million light years away galaxy was moving away at the speed of 5.5 million Miles per hour.while 200 million light years away galaxies were speeding away at 11 million miles per hour.The  logical conclusion was that the universe is expanding. The question is why ? When the matter present in the entire universe was measured it turned out that it was barely 5 % of what would be needed to explain this expansion .( one needs energy or matter to have such an expansion ). The invisible energy is called the 'dark energy' . (the matter which is not seen , but is present and contributes about 24 % of this is called Dark matter . )
          The dark energy has certain qualities . It is dark . means we can't see it , as it does not 'react' with any matter at all.It is distributed in the universe equally. or smoothly.. That means the presence of big or small objects or galaxies does not make a difference in the concentration . It is 'same ' all over.And lastly , even with the universal expansion , it does not get 'diluted '.That means the amount of dark energy continues to be same all the time and  every where.
        So now that we know the properties of the dark energy, does it have any similarity with anything that we know? If we think about the 3 'bodies ' that are described in the vedic religion , we know that there is 'causal ' body, there is 'astral ' bodyand there is 'physical ' body . When I talk about the body , I am talking about everything IN THE UNIVERSE , that has 3 bodies . That means there are 3 plains one is causal , one is astral and one is physical . We all can see and feel the physical universe . But we DO NOT SEE OR FEEL the astral or causal universe . The causal part of the universe is nothing but the 'energy'. If we narrow down the observation to our own human body , we know that inside the physical body , we have astral body, which is identical to the physical body , except that it does not have physical elements . It still has eyes , ears ,etc and also has mind , ego , intellect etc. Inside this astral body,  is CAUSAL body. The causal body is the Cause of the 2 other bodies . It is the source of the energy, for the 2 other bodies . To explain this , let me take an example of the computer. I am writing this blog , The energy needed to run this computer, is coming from the battery , but if the battery runs out , I have to 'recharge ' it . So I plug it in wall outlet for the electricity. But the electricity does not come from wall outlet, it comes from the power company, The power is generated from various sources. The power for the human body or the entire universe comes from the GOD. this the 'hidden ' ,'unssen' energy , we can  'feel' it,which means we have indirect proof of it but can't see it ,It does not react with matter ,( enenthough the causal body is inside the astral body , it is not affected by it), it does not get diluted , and it is equally present in same concentration all over the universe . So to me the dark energy is the CAUSAL energy of the causal universe .

Wednesday, September 5, 2012


    When I was in medical school , I was taught the basics of medicine .We were very young and were taught proper way of taking history and proper way of examining patients . We had to do this in every case even if the diagnosis is obvious. It may be due to lack of all the tests that are available today , like CT scan, PET scan , echo cardiogram or stress tests or many other tests , but we had to be sharp in our history taking and our examination skills. Thank God that I have not left this habit , now that we have every patient getting all these tests .The case that I am going to describe is one that is illustrative of this fact .
     I was called in for a consult in Intensive care Unit . Patient was a 70 years old patient , who was admitted to hospital , with multiple medical problems . She had stroke and was admitted to hospital about 6months ago and needed to be on respirator. As she could not be weaned weaned off the respirator, she needed tracheostomy. She could not eat , so had feeding tube put in . She also had urinary catheter and had a line for intravenous medicines . She was in a nursing home . She had a routine blood test done and it showed renal function worsening. On the day of admission her blood pressure dropped , and so she was sent to hospital ER and then was admitted to Intensive care unit .
     When I saw her it was 6-30 pm . and the admitting doctor had seen her . She was also seen by kidney specialist and infectious disease specialist . They had ordered no. of tests , Intravenous fluid, and no. of antibiotics. Their notes had differential diagnosis and even a mention that  if  she did not improve, she would need dialysis. I saw her , spoke to the nurse and examined her . She was on respirator with history of stroke , so was unable to talk or communicate much.
     The CT scan of chest and abdomen were ordered .I saw her and EXAMINED her . I told the nurse that she needed to change the urinary catheter .She told me that the catheter was working 'fine ' as there was urine coming out .I told her to change it anyway as it was blocked and if it was changed , her kidney function would be most likely be normal by AM. I left ICU .
      By next morning , when I saw her she had put out 3700ml of urine in 12 hrs. and her kidney function was almost normal . Her blood pressure was normal and she was 'fine'.
    When I was in medical school ,we had to do 4 phase examination . ,Inspection , Palpation , percussion and auscultation . It did not matter if patient had obvious hernia or we were doing chest examination .If we did not follow this sequence , and  that to a point of being seen by our teacher , he would hit on our hand . We must first 'inspect' then 'palpate ' then the last two . In the patient , that I mentioned , when I felt her abdomen , I felt huge , distended bladder. (All other doctors had written that there was feeding tube and there was no mention of any other findings and definitely not that of distended bladder. )She did not have 'sepsis' nor did she need any dialysis. All that she needed was simple change of her catheter.. So in the age of all the scans , and other tests that we have , we still need basics of examining patient.

Monday, September 3, 2012


    We as human being expect people to say words  like  'please',  'thank you 'etc. When people do not say these words,and do call them words as many a times they are mere words ,we get upset. But there are times when we do not expect someone to say it and people say it .  we are left asking a question  'for what ' , though we do not say it loudly. Many times  we say these things when we don't mean it . So when I received the greeting card from Martha , I was not only surprised, I did not know how to react .
     I saw Tom in my office for abnormal chest x-ray. He was 81 years old male who was referred to me for abnormal x-ray. He had persistent cough . So he went to his primary care physician and was treated . When the cough did not improve , he had the chest x-ray . It showed a patch of pneumonia . He was treated and the x-ray was repeated . The x-ray did not show  improvement, so he was sent to me .
    He was accompanied by his daughter . He was a retired cop. His wife had passed away 3 years ago and his daughter had moved with him . He had no major medical history. He had high blood pressure.He had lost 15 lbs. He had mild memory loss . He still walked a mile without getting short of breath.. I ordered a CT scan and did pulmonary functions . The CT scan showed a collapsed of left lower lobe ( lower third of the left lung ). I did bronchscopy and it showed the tumour in the lower lobe . It was blocking the opening of the left lower lobe.This had caused the persistent pneumonia. I did the biopsy and it did come back positive for cancer. So I had a talk with him and the daughter.The breathing test was not normal . It did show reduction in the lung capacity . But it was still acceptable for cutting lower third of the left lung to get rid of the cancer . This would be the best treatment . The alternative would be to give him radiation treatment . The surgery is the only treatment which if successful , can cure the cancer . The other treatments can help , reduce the size of the tumour , but in most cases can't cure the cancer . After the discussion they agreed for the surgery .
    He had the surgery . Unfortunately at the time of surgery , the surgeon noted that the tumour was stuck to the central area , and the central lymph nodes  were involved . The fissure that separates the lower lobe from upper was incomplete and the tumour had spread to the upper lobe as well . This was not obvious on the CT scan . He had no choice but to take out entire left lung . The post operative course was not very good . He was on the respirator and we had difficulty weaning of it . Every time we went down to 4 breaths ,he would get short of breath, and we had to sedate him . I did try for next 10 days . I knew that if we could not wean him off the respirator by 2 weeks or so, we will have to do tracheostomy . I did discuss this with the daughter . After that we made him DNR. DO NOT RESUSCITATE .
    On the 13th day , it happened . He suddenly became short of breath, and his blood pressure dropped . I did a chest x-ray and it showed left chest full of air . The stump had ruptured . (When the lung is taken out, the main bronchus is cut and sutured . It heals and we don't have problem . But in this case due to the respirator , which 'gives' breath of air, it causes increase pressure  with the breath . Due to increase stiffness of the remaining lung the stump ruptured , and that caused the drop in oxygen and the blood pressure .) We put in a chest tube to allow the air that was leaking , to get out . But this did not help . Now the air that the respirator was pushing in with each breath , was leaking out.and the right lung was not getting enough air . So we were unable to oxygenate well . I talked to the daughter . I had done what I could . The surgeon had called to take  him to the surgery , as it was only option . After the discussion the, daughter refused the repeat surgery.Her feeling was that 'he had gone through enough '. Her point was well taken as  even if we were successful in closing the air leak, he was going to be on the respirator, and would have needed tracheostomy. I called the surgeon and cancelled the surgery and made him DNR and he died in next couple of hours . The daughter was present in ICU.
    Ten days had gone since Tom had died .  I was in the office. My secretory told me that the daughter had come to talk to me . I called her in . She handed me a card . It was a 'thank you ' card and she had her personal note in it . She wanted to thank me personally .
    For next 5 years , she came personally and gave me the 'thank you ' card !!!!!